Beta-blocker vs ARB in Marfan Aortopathy — EECC MCQ

Correct answer: B — Beta-blockers remain the first-line pharmacotherapy for Marfan aortopathy; the COMPARE trial showed irbesartan added to beta-blocker reduced aortic root growth rate, but losartan did not show clear superiority over atenolol in head-to-head trials — combined beta-blocker + ARB may provide the best protection

Pharmacotherapy for Marfan aortopathy per the ESC 2024 Aortic Disease Guidelines: (1) Beta-blockers: the original standard based on the Shores et al. trial (1994) — propranolol slowed aortic root growth rate; mechanism: reduce dP/dt (aortic wall shear stress) by lowering HR and contractility; (2) ARBs: theoretical advantage via TGF-β pathway inhibition (TGF-β excess drives Marfan aortopathy). Clinical evidence: COMPARE (2011) showed irbesartan added to beta-blocker reduced aortic root growth; however, head-to-head trials (Atenolol vs Losartan — Pediatric Marfan trial) showed NO superiority of losartan over atenolol; (3) Current recommendation: beta-blocker as first-line (Class I), ARB as alternative or add-on (Class IIa); combined therapy may be optimal. Target: HR <70 bpm, SBP <120 mmHg. ALL Marfan patients with aortic root dilatation should be on pharmacotherapy regardless of aortic size.

Reference: ESC (2024): Aortic Disease; COMPARE Trial